Honorary Life Member Nominations
Nominee's Full Name
*
First Name
Last Name
Nominee's Email Address
*
example@example.com
Nominee's Phone Number
*
Please enter a valid phone number.
Format: (0000) 000-000.
Please provide a statement of the Nominee's contribution, including the nature and extent of their service or achievement:
*
Please provide a statement outlining how the Nominee's actions have positively impacted CCCWHC, its members, or the broader community:
*
Is the nomination for sustained service or a significant one-off contribution?
*
Please Select
Sustained service
Significant one-off contribution
Approximate dates of Nominee's contributions:
*
The Life Membership Nomination Form must be endorsed by two Nominator's who are current members.
Please provide the name and contact details of your chosen Nominator's.
Full Name of Nominator #1
*
First Name
Last Name
Email Address of Nominator #1
*
example@example.com
Phone Number of Nominator #1
Please enter a valid phone number.
Format: (000) 000-0000.
Full Name of Nominator #2
*
First Name
Last Name
Email of Nominator #2
*
example@example.com
Phone Number of Nominator #2
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Nomination
Should be Empty: